Q&A: Pozner Reflects on a Decade of Education Through Simulation

Charles Pozner

Praised as an innovator in medical education and for his warmth and sincerity as a mentor, Charles Pozner, MD, medical director of the Neil and Elise Wallace STRATUS Center for Medical Simulation at BWH, was honored with the Bernard Lown Teaching Award at Harvard Medical School last month.

Collaborating with then Chair of Emergency Medicine Ron M. Walls, MD, Pozner led the development of the Simulation, Training, Research and Technology Utilization System (STRATUS) Center in 2004 as a single-specialty simulation center in the department. Twelve years later, it has grown into a multidisciplinary hub for hands-on training for thousands of physicians, nurses, physician assistants, residents, fellows, students and other clinicians across 14 departments throughout the hospital and beyond.

In this Q&A with BWH Clinical & Research News, Pozner shares his thoughts on the role of simulation and his philosophy as a clinical educator.

Why did you open the STRATUS Center?

CP: We started as a single-specialty simulation center. Our original goal was to enhance the teaching that was done for our Emergency Medicine residents, which had mostly been done in lecture format. However, there is a lot of information in the literature suggesting that adults don’t learn as well in a passive state, like sitting in a classroom. We felt that by teaching with simulation—which is active, hands-on learning—there would be better transmission of information.

CP: Practicing procedures prior to having them done on real patients is an advantage for both the patient and the practitioner. By becoming familiar with a procedure prior to performing it on an actual patient for the first time, there is a reduced likelihood of error, and practitioners approach the procedure with increased competence and confidence.

Mastering a procedure should take place in the actual clinical environment under appropriate supervision, but simulations can help a caregiver gain experience, confidence and competence in a controlled environment.

Another benefit is simulation’s predictability. Learning in the clinical environment requires several elements to align: the right clinical presentation, time to provide an educational experience and a skilled teacher. Using simulation, one can be assured that each of these elements is in alignment every time. For example, if someone needs to learn how to manage a difficult airway, the last place you would send them is the operating room or emergency department. These are rare events that require prompt, highly competent care. But in the simulation lab, I can provide a difficult airway every single time. In the era of reduced trainee clinical hours, simulation is a way to ensure exposure to the wide array of clinical presentations necessary to produce a high-quality clinician. I don’t think the clinical environment is unimportant—it’s very important. But for novices, it’s a good idea to give them time to practice—not worrying about when the next patient is coming through—and allow them to make and correct their mistakes.

Aren’t participants intimidated in a simulated environment?

CP: No doubt some apprehension is created when performing in front of colleagues and teachers. I believe that there is some benefit of being a bit stressed—but not overstressed. The literature on adult learning supports this. We work hard to provide an appropriate level of stress by developing what we call a psychologically safe environment. There are a few things we explain prior to teaching with simulation that touch on this.

First, everyone comes to work wanting to do the best possible job. No one comes to work to make mistakes, but we’re human, and humans have flaws. In the simulation environment, mistakes don’t hurt anyone—we can always just reboot the computer—and you should feel comfortable making them here because we’re going to use the mistake as a means to improve your practice. In fact, we learn best from our mistakes.

In addition, we confirm that the environment is not real, but ask participants to treat it as if it were, because this will ensure that they get the most out of the experience. We work hard to suspend the disbelief of the simulated environment, and if we do our job well, participants are more likely to behave naturally, as if they were in the actual clinical environment.

We also tell people, “What happens at STRATUS stays at STRATUS.” Unless we’re doing an assessment or a research project, we don’t want people talking about what their colleagues do so that they can feel comfortable being introspective about why the mistake was made and learn how to fix it.

How has the center evolved over the last 12 years?

CP: I knew early on that I didn’t want to limit STRATUS to Emergency Medicine. I was on the Emergency Response Committee around the time STRATUS was getting started, and I suggested that we could take our mannequins to the actual clinical environment and conduct unannounced mock codes as a means of identifying latent safety risks within the institution. In 2003, we got permission to do the mock codes, and we’ve been doing them ever since.

My motivation for initiating mock codes was twofold: One, I thought it was really important for the hospital, in order to provide the best care, to identify latent safety threats before they posed actual risks to patients. I also wanted to get STRATUS’s simulators in front of people. We’re down in Neville House, and sometimes it’s hard to entice people to come down, so a little free publicity never hurt. Sure enough, people began to see us in action and realized there was benefit to this new technology. Soon thereafter, we got requests to provide programs for various specialties at STRATUS. Our reputation within the institution started to grow, and subsequently, the hospital came to us and asked us to expand.

Instead of designing the center entirely by myself, I asked the chairs to give me somebody from their departments to help me build it. I’m an emergency physician; I don’t know much about anesthesia, surgery, obstetrics—those are not in my bailiwick—so I needed those people to help me build something that would be useful to each of their specialties. I also wanted people to feel like it was their center, instead of it being “an Emergency Medicine center that expanded.” I wanted them to feel ownership in it.

The other thing we realized shortly after opening is there are other uses for medical simulation, including assessment, process improvement and research. We were the first simulation center to publish in the New England Journal of Medicine.

How would describe your style as a clinical educator?

CP: Here is what I say to my fellows all the time: If you’re not passionate about what you do and people don’t feel the energy that you get from teaching, then they’re not going to pay attention to you. You’ve got be interested in what you’re doing. I embraced simulation as one tool in education, and began to use it in an active and much more engaging way.

In addition, I think that humility is incredibly important to bring to the clinical bedside because we aren’t always going to know everything. And if we’re not accepting of our fallibility, then we’re not going to be accepting of suggestions. Our patients deserve the best care, and it doesn’t matter to them if I have the answer or the nursing student does—they just want the right thing to be done.

What do you see as your greatest accomplishment as a clinical educator?

CP: I would say the introduction of inter-professional, non-technical education into the Brigham and Women’s community, which has helped to change the culture of the institution. I think it is incredibly important—more important than almost anything else we do.

Historically, doctors trained with doctors, nurses trained with nurses, anesthesiologists trained with anesthesiologists, obstetricians trained with obstetricians and so on. However, when things happen, they most often have to come together and work smoothly as a team—and without training, why should we expect them to be able to do that?

My mantra is, “The answer is almost always in the room; it just doesn’t always get to the patient.” If I give a group of clinicians a test, there’d be a spectrum of scores. Some people would do well, and others wouldn’t. But if I gave them one test to complete collaboratively, I can almost guarantee they would get a 100 percent. Usually, when mistakes are made, it’s about lack of communication. And what we try to do here is level the hierarchies so people feel comfortable taking suggestions and speaking up when they have something to add. That’s a really critical element of patient care, which has just recently been brought to the forefront.

Brigham and Women’s Hospital has been doing inter-professional education for over 12 years, and we were the first place where doctors and nurses learned together to our patients’ benefit. That’s what I’m most proud of.